How to Support New Evidence-Based Practices in Integrated Primary Care: What Can We Take from Implementation Science?

Emily Fu, MPH, MS^✉; Integrated Primary Care SIG

 

Integrated primary care (IPC) aims to improve access to behavioral health services by embedding a behavioral health provider. This integration often proves difficult however implementation science helps to facilitate this process. Implementation frameworks such as the Implementation Research Logic Model (IRLM) may assist by accounting for the complex dynamics inherent in primary care, especially when implementing a multi-level and multi-component intervention such as IPC.

Providing behavioral health services can improve patients’ mental and physical health, quality of life, and also reduce provider burden and healthcare costs more broadly. However, healthcare providers often lack training to assess and treat behavioral health, and providers’ perceived efficacy of managing patients’ behavioral health problems is variable. IPC seeks to address this issue through including a behavioral health clinician in a primary care team or by being co-located in the clinic.                 

Implementation science brings together multi-disciplinary team members to improve the delivery and uptake of effective evidence-based practice (EBP)s through understanding multi-level organizational, contextual and leadership barriers and facilitators, and developing tailored strategies for implementation. It focuses on understanding the context and setting wherein an EBP is being implemented, with the overall goal of improving patient outcomes by successfully initiating and sustaining new programs.

Lau et al.’s (2015) review showed that EBPs too often are implemented without strategic planning prior to implementation. To support EBP uptake, IPC researchers must first engage stakeholders and leadership to agree upon shared goals that guide implementation strategies, determined a priori, and are aligned with the clinical context at hand. Next, properly adhering to implementation frameworks or logic models, such as the IRLM by Smith et al. (2020) can assist new EBPs in IPC. The IRLM is a semi-structured tool that aids in concrete design and specification of key implementation components to guide implementation and capture testable causal pathways. This model can allow IPC researchers to clearly define the determinants, organized by domains according to the Consolidated Framework for Implementation Research, develop and clarify planned implementation strategies, mechanisms of action of those strategies, and the target implementation, service, and patient-level clinical outcomes. Implementation outcomes could include the acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability of the EBP. The IRLM or other logic models and frameworks can aid IPC implementation researchers and partners in planning and executing the implementation of novel EBPs. 

 

Here are some helpful papers to assist in supporting EBPs in IPC:

Lau, R., Stevenson, F., Ong, B. N., Dziedzic, K., Treweek, S., Eldridge, S., ... & Murray, E. (2015). Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implementation Science, 11(1), 1-39.

Hunter, C. L., Funderburk, J. S., Polaha, J., Bauman, D., Goodie, J. L., & Hunter, C. M. (2018). Primary Care Behavioral Health (PCBH) model research: Current state of the science and a call to action. Journal of Clinical Psychology in Medical Settings, 25(2), 127-156.

Powell, B. J., Beidas, R. S., Lewis, C. C., Aarons, G. A., McMillen, J. C., Proctor, E. K., & Mandell, D. S. (2017). Methods to improve the selection and tailoring of implementation strategies. The journal of behavioral health services & research, 44(2), 177-194.

Smith, J. D., Li, D. H., & Rafferty, M. R. (2020). The Implementation Research Logic Model: a method for planning, executing, reporting, and synthesizing implementation projects. Implementation Science, 15(1), 1-12.

Smith J. D., Polaha, J. (2017). Using implementation science to guide the integration of evidence-based family interventions into primary care. Families, Systems, & Health, 35(2), 125-135.